Part 5 of the TED Radio Hour episode Toxic
About Rishi Manchanda's TED Talk
When Dr. Rishi Manchanda worked in a clinic in South Central Los Angeles, he saw that patients were getting sick because of toxic living conditions — so he tried a unique treatment approach.
About Rishi Manchanda
Rishi Manchanda is a physician and public health innovator. He aims to reinvigorate primary care by teaching doctors to think about and treat the social and environmental conditions that often underlie sickness.
GUY RAZ, HOST:
It's the TED Radio Hour from NPR. I'm Guy Raz. And on the show today - Toxic, ideas about human resilience in a world full of toxins and chemicals. So what if the way we think about toxins is oversimplified?
RISHI MANCHANDA: We often only look at a substance that is toxic because it's easy for us to mobilize a campaign against a villain. But what happens when we can't use a reductionist or singular approach? When we have to actually think about complexity, when we have to think about community and not just single cause.
RAZ: This is Dr. Rishi Manchanda. And he says, yeah, chemicals can be toxic. But so can a lot of other things right in our own homes.
MANCHANDA: There's no doubt that, as many public health researchers have been saying for years, that zip code matters more than genetic code when it comes to health outcomes. Where we live, where we eat, where we sleep have more than five times the impact on our health outcomes than all the, you know, pills and procedures the doctors prescribe.
RAZ: Which means if you can't afford to live somewhere with access to healthy food or green spaces or good living conditions, it has an impact on your health.
MANCHANDA: Poor communities have less say in determining how healthy their community can be or less power to actually make that happen. It's a vicious cycle.
RAZ: Rishi's seen this firsthand. He used to work at a clinic in South Central Los Angeles, which served mostly lower income and minority patients.
MANCHANDA: It was so clear that the issues that impacted my patients were informed by the toxins in their environment.
RAZ: Rishi would see a lot of kids come into that clinic with things like lead poisoning because of old paint in their homes, people with breathing problems because of mold. And in cases like that, the approach can be surprisingly simple. Rishi told the story of one patient on the TED stage.
(SOUNDBITE OF TED TALK)
MANCHANDA: Veronica (ph) was the 17th patient out of my 26-patient-day at that clinic in South Central Los Angeles. She came into our clinic with a chronic headache. This headache had been going on for a number of years. And this particular episode was very, very troubling. In fact, three weeks before she came to visit us for the first time, she went to an emergency room in Los Angeles. The emergency room doctors said let me run some tests, Veronica. The results are normal, so here's some pain medication. And follow up with a primary care doctor. But if the pain persists or if it worsens, then come on back. In the three weeks before Veronica met us, she went to the emergency room three times. She went back and forth, in and out of hospitals and clinics just like she had done in years past, trying to seek relief but still coming up short.
When she came to our clinic though, we tried a different approach. Our medical assistant asked them routine questions. She asked, what's your chief complaint? Headache. Let's get your vital signs, measure your blood pressure and your heart rate. But let's also ask about something equally as vital to Veronica and a lot of patients like her in South Los Angeles. Veronica, can you tell me about where you live, specifically about your housing conditions? Do you have mold? Do you have water leaks? Do you have roaches in your home? Turns out Veronicas said yes to three of those things - roaches, water leaks, mold.
RAZ: Of course, not all doctors ask these questions. In fact, the template for Rishi's survey, it didn't come from a doctor at all.
MANCHANDA: Actually came from the American Housing Survey. It's a survey to assess the health of our housing stock. But it asks questions that are pertinent for health issues, too.
RAZ: Questions like...
MANCHANDA: Do you have water leaks?
RAZ: Are there cockroaches in your house?
MANCHANDA: How old is your home?
RAZ: Do you have mold? Does anyone smoke in the house?
MANCHANDA: Do you have large sections of your home where paint is chipping or fraying?
RAZ: Things that can make you sick. And so Rishi and his team took those questions and they included them in a patient's exam. So by the time Rishi met with Veronica, he already knew about how her environment might be affecting her health.
(SOUNDBITE OF TED TALK)
MANCHANDA: Here she was, doubled over in pain sitting on my exam table. Her head, clearly throbbing, was resting in her hands. She lifted her head up and I saw her face. I said hello. And then I immediately noticed something across the bridge of her nose - a crease in her skin. In medicine we call that crease the allergic salute. It's usually seen among children who have chronic allergies. It comes from chronically rubbing one's nose up and down trying to get rid of those allergy symptoms. And yet here was Veronica, a grown woman, with the same telltale sign of allergies.
I said, Veronica, I think you have chronic allergies. I think you have migraine headaches and some sinus congestion. And I think all of those are related to where you live. She looked a little bit relieved because for the first time she had a diagnosis. But I said, Veronica, now let's talk about your treatment. We're going to order some medications for your symptoms. But I also want to refer you to a specialist if that's OK. I said, Veronica, actually the specialist I'm talking about is someone I call a community health worker, someone who if it's OK with you, can come to your home and try to understand what's going on with those water leaks and that mold, try to help you manage those conditions in your housing that I think are causing your symptoms. And if required, that specialist might refer you to another specialist that we call a public interest lawyer. Because it might be that your landlord isn't making the fixes he's required to make.
Veronica came back in a few months later. She agreed to all those treatment plans. She told us that her symptoms had improved by 90 percent. She was spending more time at work and with her family and less time shuttling back and forth between the emergency rooms of Los Angeles. Veronica had improved remarkably. Her sons, one of whom had asthma, was no longer as sick as they used to be. She had gotten better. And not coincidentally, Veronica's home was better, too. What was it about this different approach that we tried that led to better care, fewer visits to the ER, better health? Well, quite simply, it started with that question. Veronica, where do you live?
(SOUNDBITE OF MUSIC)
RAZ: Yeah, I mean, being exposed to chemicals isn't just the only way to be exposed to a toxic environment, right?
MANCHANDA: Yeah. I tell the story of a great research project that happened in the United Kingdom. The researchers behind the study were looking specifically at cardiovascular disease and, within that specifically, the risk of death from a heart attack.
And when they controlled for all other factors - you know, the economic level, the education level for somebody, the degree of disease that they had - what they came across was the closer an individual lived to a green space, to parks and trees, the lower their chance of dying from a heart attack.
So for me as a physician, I'm certainly aware and trained to be aware of how to find the right pills and procedures to help support a patient of mine when they're at risk for a heart attack. But how do I prescribe a park? How do we as health care providers start thinking about the influence that that exposure has? And that's what is profound for me.
(SOUNDBITE OF MUSIC)
RAZ: Asking about health factors like whether there's a park nearby or mold in your home - that's known as an upstream approach. Basically you look beyond the symptoms and toward the source of the problem. And Rishi Manchanda says there are a few reasons more doctors don't do this.
(SOUNDBITE OF TED TALK)
MANCHANDA: The honest answer is that in health care, we often treat symptoms without addressing the conditions that make you sick in the first place. And there are many reasons for that, but the big three are, first, we don't pay for that.
In health care, we often pay for volume and not value. That leads to a second phenomenon that I call the don't ask, don't tell approach to upstream issues in health care. We don't ask about where you live and where you work because if there's a problem there, we don't know what to tell you.
It's not that doctors don't know these are important issues. In a recent survey done in the U.S. among physicians - over a thousand physicians - 80 percent of them actually said that they know that their patients' upstream problems are as important as their health issues, as their medical problems. And yet despite that widespread awareness of the importance of upstream issues, only 1 in 5 doctors said they had any sense of confidence to address those issues, to improve health where it begins.
There's this gap between knowing that patient's lives, the context of where they live and work matters and the ability to do something about it in the systems in which we work.
RAZ: And that's crazy to me. It's crazy to me that more doctors aren't asking the kinds of questions that you're asking.
MANCHANDA: The great news is that there are increasing numbers of doctors and nurses and social workers and other health care professionals who have always been asking this question and are going to continue asking this question, and it's growing. The question for me, Guy, is, how do we take this ever-expanding body of information about the toxic exposures that are out there and expand our own understanding of how to - what we can do about those?
A doctor doesn't have to become a transportation expert or a mold expert or a social worker, but a doctor should certainly know how to contact a transportation expert or a social worker or a mold expert with the same ease that a doctor can call a cardiologist to take care of that heart murmur.
RAZ: Dr. Rishi Manchanda - you can see his entire talk at ted.com. Transcript provided by NPR, Copyright NPR.